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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202655
Report Date: 07/20/2022
Date Signed: 07/20/2022 12:37:54 PM


Document Has Been Signed on 07/20/2022 12:37 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:MARQUEZ LIVING I (RCFE)FACILITY NUMBER:
435202655
ADMINISTRATOR:MARQUEZ LORENZO, MARIAFACILITY TYPE:
740
ADDRESS:994 SOBRATO DRTELEPHONE:
(408) 533-2829
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY:14CENSUS: DATE:
07/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Alex MarquezTIME COMPLETED:
12:40 PM
NARRATIVE
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 07/06/2022 at 09:31am. LPA met with house manager Alex Marquez (S1). Facility Administrator Malu Marquez was at the doctor's with a resident, and gave verbal permission over the phone for Admin to sign on her behalf.

LPA toured the facility. All staff members observed to be wearing masks. Admin confirmed that all staff and residents have been vaccinated. Facility infection control plan has already been submitted. All emergency exits noted to be clear of obstruction and locks. All rooms in facility noted to be clean and well maintained. Hand sanitizers, soap, and paper supplies were observed to be available. At least 2 days' supply of perishable food and at least 1 week's supply of non-perishable food was observed on the premises. Fire extinguisher observed to have been inspected in March 2022. All cleaning supplies and chemicals noted to be in locked cabinets and closets. Staff did not take LPA's temperature nor screen for symptoms. 30 days supply of PPE was observed. Hand washing signs were observed in the facility bathrooms. Water temperature observed to be 105.2 *F in facility bathroom. Social distancing signs observed to be posted in all public areas.

During tour of resident room #3, LPA observed prescription medication for resident (R1) on top of the resident's dresser. Medication was not being administered at that moment. Upon review of R1's files, LPA noted that, according to the R1's physician's report, R1 is not permitted to administer and store their own medication.

Deficiency cited during today's visit. Advisory notes issued. Report was reviewed with house manager Alex Marquez and a copy of this report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/20/2022 12:37 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131


FACILITY NAME: MARQUEZ LIVING I (RCFE)
FACILITY NUMBER: 435202655

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/21/2022
Section Cited

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87465 - Incidental Medical and Dental Care - (h)(1) Medications shall be centrally stored under the following circumstances... (B) Determined by the physician to be hazardous if kept in the personal possession of the person for whom it was prescribed. This requirement is not met as evidenced by:
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Based on observation and records review, the licensee did not comply with the section cited above as evidenced by medication being president in resident's room despite physician's report stating that resident could not store their own medication. This posed an immediate health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2022
LIC809 (FAS) - (06/04)
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